Contract Pharmacy Details

PROCARE PHARMACY, L.L.C.
RW431112B Mary Hitchcock Memorial Hospital dba Ryan White Program

Covered Entity Details

Entity Name

Mary Hitchcock Memorial Hospital dba Ryan White Program

Subdivision Name

Dartmouth-Hitchcock Manchester, Ryan White Part D

Type

Ryan White Part D

340B ID

RW431112B

Entity Address

100 Hitchcock Way
Manchester, NH 03104

Grant Number

H12HA31112

Participating Start Date

1/1/2019

Last Recertification Date

2/28/2022

Entity Termination Date

4/1/2023

Pharmacy Details

Pharmacy Name

PROCARE PHARMACY, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203

Pharmacy Comments

Contract Details

Approval Date

10/20/2022

Contract Begin Date

10/25/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/20/2022

340B Drug Pricing Program Database